“Doing ACT raises common, predictable challenges. In almost every case they are best overcome by stepping into the ACT model and its foundations with your head, your hands, and your heart. This gentle but wise book shows how to do that— and on all three of those levels. It is indeed Advanced Acceptance and Commitment Therapy— not because it applies only to those who are advanced, but because it teaches you how to advance. You don’t have to be an ACT expert to buy it, read it, and benefit from it— but if you buy it and read it, I guarantee that you will be much more expert in the ACT work you do.”
— Steven C. Hayes, PhD, cofounder of Acceptance and Commitment Therapy (ACT)
“It’s rare that I read a textbook that’s so good, I don’t merely want to recommend it, I want to actually rave about it— in a very loud voice! Advanced Acceptance and Commitment Therapy is such a book: a truly superb advanced- level textbook for the ACT practitioner who already has a handle on the basics, but now wants to evolve a more fluid, flexible, and effective style of ACT. I confess to having frequent pangs of envy as I read this book (which I devoured cover to cover in the space of one week) and many thoughts such as, I wish I’d written this. It’s easy to read, extremely engag-ing (in parts, laugh- out- loud funny), and incredibly practical. Even highly experienced ACT practitioners will get a lot from this book. I certainly learned new things from reading it, and I’ll bet good money that you will too! … So if you’re ready to move from the beginner level ‘ACT- ish therapy’ to genuine, high- powered ACT, then rush out and get this book now!”
— Russ Harris, author of The Happiness Trap and Getting Unstuck in ACT
“As I read Advanced Acceptance and Commitment Therapy, I kept turning to my per-sonal knowledge of Darrah Westrup and her incredible ability to communicate, in writing, her gifted therapeutic experience and understanding of ACT. I know Darrah as both a colleague and a friend, and this book shines a bright light on her amazing talent and facility with the intervention. Readers will be engaged from the opening pages regarding theory and processes, through the thoughtful and seasoned applica-tion of ACT, all the way to its invitaapplica-tion to continue the ACT journey at the book’s close. She brings to this volume not only a digestible, considered, and at times humor-ous read, that every therapist, not just those using ACT, will find invaluable, but also a personal sense of herself that is kind, grounded, and compassionate. Thank you, Darrah, for this beautiful contribution to the ACT community and therapist com-munity at large.”
— Robyn D. Walser, PhD, associate director of dissemination and training at the National Center for PTSD, director at TL Consultation Services, and assistant clinical professor at the University of California, Berkeley
“Advanced Acceptance and Commitment Therapy is an invaluable resource for every therapist who doesn’t just want to do good ACT but great ACT. Easy to read and very practical, this book succeeds at linking concrete skills to deep philosophical and behavioral principles underlying the ACT model. The numerous clinical vignettes are commented with great precision and clarity, and show how to activate key processes through natural interactions, beyond traditional exercises.”
— Matthieu Villatte, PhD, research scientist at the Evidence- Based Practice Institute, Seattle; ACBS- recognized ACT trainer; and associate editor of the Journal of Contextual Behavioral Science
DARRAH WESTRUP, P
h
D
New Harbinger Publications, Inc.
Advanced
A
cceptance
&
C
ommitment
T
herapy
The Experienced Practitioner’s
Guide to Optimizing Delivery
Publisher’s Note
This publication is designed to provide accurate and authoritative information in regard to the subject matter covered. It is sold with the understanding that the publisher is not engaged in rendering psychological, financial, legal, or other professional services. If expert assistance or counseling is needed, the services of a competent professional should be sought.
Distributed in Canada by Raincoast Books Copyright © 2014 by Darrah Westrup
New Harbinger Publications, Inc. 5674 Shattuck Avenue
Oakland, CA 94609 www.newharbinger.com Cover design by Amy Shoup
Acquired by Catharine Meyers Edited by Susan LaCroix Indexed by James Minkin All Rights Reserved
Library of Congress Cataloging-in-Publication Data
Westrup, Darrah.
Advanced acceptance and commitment therapy : the experienced practitioner’s guide to optimizing delivery / Darrah Westrup, PhD.
pages cm
Summary: “In Advanced Acceptance and Commitment Therapy, a licensed clinical psychologist and renowned ACT expert presents the first advanced ACT book for use in client sessions. Inside, readers will hone their understanding of the core processes behind ACT and learn practical strategies for moving past common barriers that can present during therapy, such as over-identifying with clients or difficulty putting theory into practice”-- Provided by publisher.
Includes bibliographical references and index.
ISBN 649-0 (paperback) -- ISBN 650-6 (pdf e-book) -- ISBN 978-1-60882-651-3 (epub) 1. Acceptance and commitment therapy. I. Title.
RC489.C62W47 2014 616.89’1425--dc23
2014006466
Contents
Acknowledgments . . . v
Introduction: Where It All Begins . . . 1
PART 1
Getting Oriented
1
Let the Theory Guide the Way . . . 7
Diving In
The Aim of ACT
The Means of ACT
What aboutRFT?
The Core Processes of ACT
Problems with the Processes
Either In or Out
Quick Tips for Staying on Point
Summary2
Starting Off Well and Staying the Course . . . 27
Session Objectives
The Importance of Structure
Staying on thePath
Preparation Is Good, but Being Present Is Better!
Principles over Planning
Summary3
Style Matters . . . 45
Individuality, but Not at the Cost of Fidelity
Actual, Not Theoretical,Equality
Getting in the Room
Sharing as Contribution
The Gift of Transparency
Nurturing or Enabling
Support Does Not Mean Aligning
Summary4
Let’s Talk About Timing . . . 67
The Importance of Being Present
The Gift of Silence
When in Doubt, Listen
Explicit vs. Implicit Work
CommonTiming Missteps
Summary5
Know Your Approach . . . 81
To Sequence or Not to Sequence
Other Considerationsiv
Advanced ACTPART 2
Tricky Little Pieces and Common Missteps
6
That Little Problem Called Language . . . 105
Letting Language Off the Hook
Why Go There?
What Is Needed?
Description vs. Evaluation
The Mind Is Not All That
Summary7
Help with Creative Hopelessness . . . 123
Why So Hard?
Bailing Out
Fragility or Fusion?
Once Again,the Importance of Style
Other Stylistic Missteps
The Heart of the Matter
It’s About the Larger Agenda
Creative Hopelessness Lite
Summary8
Barriers to Treatment . . . 147
How to Spot Barriers
What to Do
Common Barriers toBehavioral Change
When Clients Don’t Progress
Summary9
The Conundrum of Self- as- Context . . . 175
The Struggle
What Is the Self, Exactly?
How Does SelfHappen?
Is the Self the Soul?
What Are We Aiming For?
So How Do We Go About It?
Other Perplexities
Summary10
Optimizing Your Secret Weapons . . . 193
Why So Hard?
Winging It
Not Going for It
You, but Not Me
Timing, Yet Again
Why Can’t the Passengers Drive the Bus?
Turning Buses into Shovels
Some Stickiness with Mindfulness
Use What Works
SummaryPART 3
Some Finer Points
11
Curveballs and Consistency . . . 219
Oh, by the Way…
Bad News
In Pursuit of Happiness
Summary12
Your Continued ACT Journey . . . 235
Claiming Your Barriers
Living Your Intention
Walking the Walk
Ways to Grow
Lonely in ACT- ville
ConclusionReferences . . . 245
Index . . . 249
Acknowledgments
I
would like to thank my patient copy editor, Susan LaCroix, and the rest of the folks at New Harbinger for being so consistently great to work with. Thank you, Tammy Hoier and Mike Todt, for your support and feedback, crucial “Chloe cov-erage,” and the gift of the perfect writing space at the perfect time. I owe the eagle- eyed Matthieu Villatte a huge thanks for his generosity, time, and wisdom. I feel the need to acknowledge Steven Hayes’s big brain and all the other big brains that have contributed to this technology. How extraordinary to have developed something with so much potential to improve the human condition! I give a heartfelt thanks to my forbearing husband and daughter for those precious weekends, evenings, and untold other sacrifices. You give me the gift of being present and in the business of active loving every day. Finally, I wish to thank all the consultees, trainees, and supervisees with whom I’ve had the great fortune to travel, and who are in large part responsible for any wisdom contained in these pages.I N T R O D U C T I O N
Where It All Begins
T
his is my sixth attempt to introduce this book. Since previous efforts to ease into my purpose here while also avoiding discomfort have failed, I’ll just be direct with why I felt there was room for a book of this sort. It has been my observation (starting with my own history) that there can be a real gap between being trained in or otherwise learning about Acceptance and Commitment Therapy (ACT) and doing it effectively. If you have worked with ACT you may have experienced this as well. In fact, that may be one of the reasons you have picked up this book. There are a couple of things that stand out for me about this gap. One concerns the degree of departure many ACT therapists make from the model, despite the proliferation of ACT trainings and a wealth of excellent ACT texts and learning materials. So while there is no shortage of information on how to conduct ACT with fidelity, I have observed that what actually happens in real- world sessions is often something quite different. This has important theoretical implications, but it is the practical consequences that will be examined most closely in this book. The other aspect that seems important is the commonalities in the struggles many therapists have with ACT. There are certain areas where providers tend to flounder, and typical difficulties and missteps that seem to be made by nearly everyone at some point or another. That’s actually good news, for if particular pitfalls are that predictable then certainly they can be talked about and worked on.It took me a few years to move from learning about the therapy to putting it into practice. Although I had previously completed a two- day ACT workshop run by Steven Hayes, and had read various ACT texts and even completed an ACT- related dissertation back in ’97, something had prevented me from actually implementing the therapy. I can best describe this as a vague yet pervasive fear that I might do some-thing wrong. Not only was I unsure of how to proceed, I was pretty sure I would not know what I was doing much of the time. Turns out I was right. In my subsequent work as a training supervisor and ACT consultant, I have found my experience to be a
2
Advanced ACTnatural and essentially unavoidable one for therapists working with ACT, and that this is about more than learning something new. The fact that ACT is so firmly rooted in a coherent and fleshed- out theory— that it was built from the ground up as the clinical derivative of established behavioral principles— means that there is a distinct model in ACT that is either being followed or not. And just because it’s elegant doesn’t mean it’s easy. The fundamental tenets of ACT directly oppose ideas supported by our culture (and our own minds), making it very easy for therapists to purposefully or inadver-tently depart from the model to varying degrees. This departure poses a theoretical dilemma, because unless you are conducting ACT in a way that is consistent with the principles upon which it is based, you are contradicting the entire model. Clinically speaking, conducting ACT in this way hamstrings the therapy. Or rather, the greater the congruence with the model, the more powerful the therapy will be.
Discomfort shows up again as I make such sweeping statements. I am embold-ened, however, by my experience supervising numerous psychology interns, practicum students, and postdoctoral fellows in conducting ACT, which typically has involved direct observation and cofacilitation. I also work as an ACT consultant for various organizations and individuals, including serving as an expert ACT consultant for a nationwide rollout of ACT in Veterans Affairs. I have participated in this last project for the past five years. It involves working with groups of providers over a period of six months, listening to taped sessions and providing weekly feedback. This particular project has provided me a window into the experiences of seasoned providers as they conduct ACT over time with a variety of individuals. Needless to say, the project has significantly enhanced my own ACT skills. At last count I have reviewed and provided critical feedback on well over 1,000 ACT sessions. All together, these experiences have taught me a great deal about ACT and its challenges, and convinced me of the value of passing what I’ve learned on to others interested in this therapy. I certainly have had a chance to see what does and doesn’t work.
My intention with this book is to be helpful at the clinical level, to offer substan-tive assistance with the common barriers and challenges encountered as therapists conduct the therapy with actual clients, and to help those working with ACT to opti-mize what the therapy offers. A major thrust of this book is that in order to do ACT well, therapists need to approach the therapy from the behavioral principles forming ACT. Doing so, of course, requires familiarity with those principles. (As we work with the various clinical issues discussed in this book, I’ll sometimes refer to this stance as operating from within the ACT framework, or as looking at the therapy through an “ACT lens.”) This is why we begin in part 1 by taking a look at theoretical underpin-nings of ACT, as this is the place from which everything else flows. Similarly, the way in which sessions are structured, pacing, and the manner in which the therapist shows up in the room play a major part in how well (or not) the therapy will go, so we will explore these topics before moving on to specific components of the therapy. Part 2 tackles common difficulties encountered when therapists approach the main components of ACT— such as the role of language, creative hopelessness, and self- as- context— and will explore ways to work with some of the barriers that tend to show up
Where It All Begins
3
over the course of the therapy. The last section, part 3, examines the more subtle issues that are no less significant in terms of their impact on ACT sessions.It is important to note at this point that the clinical examples provided through-out the book are either fictitious or amalgams of various clinical scenarios and indi-viduals I have encountered over the course of my supervisory, consulting, and personal clinical work. While my intent has been to capture “real life” examples of this therapy and its challenges, care has been taken that no particular individual or therapeutic situation can be identified. For example, when pulling out an actual snippet of dia-logue in order to make a point, I have altered other information as a way to protect confidentiality.
I would like to add, before jumping in, that although the learning curve in ACT can sometimes seem steep, the slope can be short, or certainly shorter than it might seem when you’re slogging up the steep part. Many of the common missteps, once rectified, help the rest of the therapy come together. In addition, as therapists our own experiences during this process offer up countless opportunities to apply and practice ACT principles in our own lives. These opportunities not only give us a deeper appre-ciation of the relevance of these principles but offer a firsthand account of what our clients are experiencing as well. Nonetheless, the challenges of conducting ACT well can be disheartening even to the most determined practitioner. It is my intention with this book to identify the areas where therapists tend to struggle, and then work with these in a way that will prove helpful to those traveling this particular journey.
It is at once humbling and exciting to think that at this moment someone is reading this sentence and contemplating whether there might be something of per-sonal value in these pages. My hope is that there is, and that you will ultimately lay down this book feeling encouraged and inspired to take this powerful therapy as far as it can go. So let’s get to it!
PA R T 1
C H A P T E R 1
Let the Theory
Guide the Way
S
ince this book is about optimizing ACT, it makes sense that almost immediately we bump up against the issue of fidelity. I’ve already been up front about my belief that fidelity to the model increases clinical effectiveness, as well as my observation that many therapists depart from the model to varying degrees. For most, this departure is not intentional. That is, many of the therapists with whom I have worked wholeheartedly buy into the importance of the ACT model, but for reasons we’ll be exploring in these pages, they can struggle with translating ACT principles into what is going on in session. So even if the intention is to work consistently within the model, there seems to be no end to ways, large and small, that we can inadver-tently do something inconsistent in session. Such moves are not always accidental. I have worked with many therapists who are simply less concerned with conducting ACT with fidelity, who might intentionally choose to move off the model here or there for various reasons. In many cases congruence with the theory behind ACT is just not viewed as being that clinically important.One potential reason for this view is that ACT can be seen as dovetailing with a previously held philosophy or therapeutic orientation that has simply not required the sort of articulation we see in ACT. For example, therapists with backgrounds in mindfulness, narrative, or other acceptance- based approaches find many of the central ideas in ACT familiar and consistent with what they have already been doing— doing without the benefit of an evidence- based theoretical model. The difference in language used by the scientific and clinical domains of ACT has not helped. It’s not just that there’s a difference, but that the language differs so much in feel. Whereas an ACT therapist will speak to clients about “accepting what is” and “making choices accord-ing to deeply held values,” the researcher might discuss “comaccord-ing into contact with
8
Advanced ACTdirect contingencies” or “verbally construed consequences that establish intrinsically reinforcing behavior.” There is a warm and fuzzy feel to the language used in the therapy, whereas the language used in the science is necessarily technical and precise. Not particularly friendly, in other words. The bottom line is that without translation it isn’t immediately clear how one domain pertains to the other, and the technical language can simply turn off therapists who were particularly drawn to the language of the therapy.
I have also found that sometimes therapists miss the fact that in ACT, the theory is the therapy. It is understandable but misleading to view the theory as being “behind” the therapy, as simply supporting or explaining the clinical piece. The discussion topics, exercises, and metaphors suggested in various ACT texts are used to advance core behavioral processes found to be central to psychological flexibility. These pro-cesses are the point, not all the technique. It is significant that this topic is addressed in virtually every ACT text, and yet many providers approach the topics, metaphors, and exercises (the technique of ACT) as being the point rather than illustrating the point (the processes of ACT). As we will be exploring, this approach has the effect in the therapy room of actually working against the very abilities you are hoping to develop in ACT.
To summarize, there is a perception by many therapists that the clinical and theoretical domains pertinent to ACT are bound only by ideas, that the theory matters chiefly at an academic level rather than having an active role in the therapy room. In fact, theory drives the entire intervention in ACT, whether or not the therapist would articulate the therapeutic process in this way. As we will be seeing in the pages to come, when it comes to clinical decision-making in ACT, the theory is the therapist’s best friend.
DIVING IN
And now I face a couple of challenges: Based upon the numerous ACT therapists I have encountered, I imagine that readers of this book could include those who are highly familiar with the theory and science behind ACT, those with little familiarity and little interest, and of course everyone in between. So one challenge is to provide a useful orientation to the rest of this book while not turning anyone off or boring anyone to death. The second challenge concerns how far into detail to go with this material. ACT is 1) a culmination of a particular worldview and approach to science (functional contextualism), 2) a particular approach to behavior (radical behaviorism), and 3) a particular methodology (applied behavioral analysis) which, when applied to the processes of human thinking and language acquisition, resulted in 4) a particular theory (relational frame theory) that informs the therapy. As it stands today ACT is considered one clinical piece of a larger and rapidly expanding area of science with the specific aim of applying functional contextualism to behavior (contextual behavioral
Let the Theory Guide the Way
9
science). In short, the schools of thought and areas of study just mentioned have their own histories, objectives, and implications. Together they represent the evolution of a particular way of approaching human behavior that manifests in this therapy we call ACT. They are therefore each deserving of close examination, particularly in what is being put forth as an “advanced” text. However, their very depth and cogency make that unrealistic here for reasons of scope alone. This is a highly clinical book, and there is plenty to talk about using clinically directed language. What to do?I have decided to approach this question as pragmatically as possible. That is, while any point of discussion in this next section could be taken further (in other words, could get more technical), I hope to stay at a level that translates fairly obvi-ously to what we do in session. Although each of the areas of study listed above has contributed to the psychological model forming ACT, some principles and processes are particularly evident in the therapy room. As I work through some of the common barriers in ACT in this book, for example, we will see how increased clarity regard-ing these principles can optimize decision-makregard-ing and help prevent common missteps. However, some additional context is needed to understand how principles derived from these areas of study fit together so that we approach the therapy in the way that we do— with fidelity, in other words. So how do the principles and processes fit together?
THE AIM OF ACT
Let’s start with the overarching objective of ACT, which is to help clients develop psychological flexibility. In their seminal book, Acceptance and Commitment Therapy: The Process and Practice of Mindful Change, Steven Hayes, Kirk Strosahl, and Kelly Wilson offer the following definition: “Psychological flexibility can be defined as con-tacting the present moment as a conscious human being, fully and without needless defense— as it is and not what it says it is— and persisting with or changing behavior in the service of chosen values” (2012, pp. 96– 97). A simple way to think about psy-chological flexibility is that it’s the ability to respond to life in a workable way, a way that enables us to live vital, meaningful lives.
This question of workability is a fundamental aspect of the therapy. From understanding what the client is pursuing in therapy, to determining what to target, to deciding how to respond to something that occurs in session, we look to work-ability as our guide in ACT. Asking whether or not something is workable is asking about its function. That is, what function is a particular behavior serving in the cli-ent’s life, in the particular situation being explored, even in this moment? How will a particular response on our part function in this session? These questions cannot be answered without considering the consequences of the behavior in question, both short- and long- term. In other words, the function of a specific behavior depends upon the context in which it occurs, specifically upon what follows the behavior. So in ACT
10
Advanced ACTwe are very interested in function, which necessarily involves the relations between whatever behavior we are considering and its particular context.
In this pragmatic focus in ACT we can already see the respective influences of two of the four areas mentioned previously: a particular worldview and approach to science (functional contextualism), and a particular approach to the study of human behavior (radical behaviorism). Functional contextualism is a philosophy of science that views an event or act as inseparable from the context in which it is embedded. Since there is no way to examine anything completely separate from its context, there is no way to establish its inherent “truth” (or “reality” or “correctness”), as that is always going to be influenced by its context (which cannot be separated out from the event or act in question). The focus of functional contextualism is accordingly and pragmatically on prediction and control of events, rather than on attempting to uncover or establish their inherent truth or rightness. To a functional contextualist, “what’s true is what works” (Hayes, Strosahl, & Wilson, 2012, p. 33). This philosophi-cal approach to science is reflected in the influential school of psychology known as radical behaviorism. That is, radical behaviorism also recognizes that there is no way to uncover or prove the inherent trueness, or rightness, or correctness of something— in this case, behavior. It is context that determines how a behavior functions. Like func-tional contextualism, the focus is pragmatically on prediction and control, specifically the prediction and control of behavior toward a desired end. The point is that ACT’s focus on workability, on the function of behavior as determined by context, is based upon these fundamental views of the world, of science, and of behavior.
There is another implication: what is not a focus in ACT. In ACT we do not approach client behavior (which is meant to include internal thoughts, feelings, and sensations as well as overt actions) as being inherently bad, or abnormal, or as a symptom of something that is inherently bad or abnormal. This again is because the normality or abnormality of something, its correctness or incorrectness as a “truth,” cannot be established (because it cannot be separated from context and its influ-ences). Working with the categories abnormal and normal is therefore not productive. So when considering a particular behavior in ACT (such as anxious thoughts or feel-ings, depressive mood, traumatic memories, or drinking alcohol) we do so from the pragmatic standpoint of how it is functioning for the client.
This pragmatic focus is quite different from many other “mental health” approaches. If we give up viewing behavior as inherently bad or abnormal, there is no need to attempt to fix, heal, or otherwise alter the actual behavior. In fact, if it is function (as determined by context) that determines workability, it would follow that targeting function, rather than behavior per se, would be a productive goal. This is one reason why, in ACT, we don’t strive to fix or eliminate behaviors that other approaches might view as abnormal or unhealthy—such as anxious thoughts, intrusive trauma memories, depressive feelings, or urges to drink. Instead we focus on altering how they are functioning in our clients’ lives. So not only have the philosophy and theory forming ACT influenced what we are ultimately shooting for; they directly guide how we go about getting there.
Let the Theory Guide the Way
11
THE MEANS OF ACT
So far I have pointed to the focus on workability in ACT; how this focus necessarily involves an examination of how behaviors are functioning for clients; and the fact that this, in turn, means considering the context in which they occur. But how do we go about this? Once a behavior is determined to be unworkable, what do we do then? This is where the other two areas of study, applied behavioral analysis—specifically functional analysis—and behavioral learning principles, come in. (And, in this and the next few paragraphs, we will also have a perfect example of that disconcerting dif-ference between the language used in the science and that used in the therapy room.) Heading in fearlessly, when we talk about the functional analysis of behavior, we are referring to an examination of the relations between a particular unit of behavior and certain contextual variables that influence that behavior. We look at what was going on in the environment, the presence of which made the behavior more likely to occur (also called a setting event or antecedent), and what followed the behavior that made it more or less likely to occur again (the behavior’s consequences). This terminol-ogy helps define the focus of study—meaning the behavior in question— which could be a small unit of behavior (for example, smoking), a smaller unit still (such as the act of inhaling), or a larger set of behaviors (such as coping strategies). Functional analysis of behavior also articulates the relations between that behavior and its antecedents and consequences. That was a mouthful! And yet it describes what we are continually doing as human beings. Whether we know it or not, we continually engage in func-tional analyses in our daily lives.
Everyday Ol’ Functional Analyses
Imagine for a moment that you are sitting in a movie theater and a wad of paper hits your head. Your first response, after blinking, would be to determine what in the heck just happened. By that I don’t really mean the what— you already know that: a wad of paper hit your head. You would be interested in the why. Not just the why at a descriptive level, as in “The paper hit my head because someone propelled it in a trajectory consistent with where my head was positioned,” but why at a functional level: “What was the purpose of that wad of paper hitting my head?” And not only would you immediately seek the answer to that question in the current context (in other words, who threw that and why); you would almost as immediately be formulat-ing an answer: “Oh, my friend Jane two rows back saw me here (the antecedent) and threw that (the behavior) to get my attention (the consequence).” Note that it was the result of her throwing the paper wad that determined its actual function for Jane. That is, if you hadn’t felt the wad of paper and turned your head, her throwing it wouldn’t have served the function of getting your attention. Also, if instead of Jane, it were a surly- looking teenager scowling at you who’d thrown the wad of paper, you might
12
Advanced ACTcome up with a different analysis for the incident altogether. The point is that we are constantly engaging in functional analyses as a way to understand our world and form our responses to it.
As therapists, too, we automatically look to context to determine how to inter-pret client behavior. If my client informs me that he turned down a dinner invitation, for example, declining means very little in and of itself. It is the current and historical context that determines how I respond to this, and it is something I begin to take into consideration the moment I hear that he declined. If he experiences anxiety in social situations (antecedent) and declines (behavior) as a way to avoid the anxiety (conse-quence), yet wants to be more connected with others, I would respond one way. If he is in early recovery from alcohol abuse, and staying away from these sorts of situations increases the likelihood he stays sober, I would respond in another. Perhaps he has a history of avoiding social situations but on this particular evening had the flu. In each case the workability of the client’s behavior rests upon how it is functioning for him, which in turn rests upon the consequences in the particular context we are examining. If we look only at the more immediate context, declining might be deemed workable because a consequence was tension relief. Looking at a larger context— say his social network— declining may not be so workable if it ultimately increases his isolation.
Everyday Ol’ Learning Principles
In the scenario just described we immediately recognize there are important dif-ferences in the various ways a therapist could respond. We can even make educated guesses on which response would be best depending on the situation. But let’s take a closer look. Why do we reject one possible response and select another? How do we know one will serve better than another depending upon the context? Because our own learning has taught us about learning. Just as our behavior, past and present, is the product of fundamental learning principles, we have learned how to utilize these prin-ciples to analyze and influence others. We have learned from experience, for example, that our responses form a consequence, that we can influence client behavior in this way, and that we can predict how our influence will impact (function for) the client.
Consider the following example: When your client takes a risk and hesitantly shares an experience of being raped that has been the source of much shame and suf-fering, you immediately consider how best to respond. That is, although you might find yourself feeling as though you want to avoid the topic, or perhaps thinking, “She never should have trusted that guy,” you would likely refrain from expressing these thoughts and feelings because you can predict the way this might impact the therapy. In fact, a reasonably seasoned or skilled clinician would likely be formulating his response with awareness that he might do something that could increase the client’s shame and secret- keeping (for example, reacting with disgust or offering a harsh judgment), as opposed to something that would make her more likely to share shameful ences in future sessions (such as listening compassionately and validating her
experi-Let the Theory Guide the Way
13
ence). There would be recognition that his responses could result in new learning. For example, the client might learn that she can share such a secret and remain safe, that she will not be rejected by the therapist (although her mind and even previous experience has told her otherwise), and that she can tolerate the experience of talking about it. In this sense the therapist recognizes that he might be able to alter how the experience of having been raped functions for the client. In fact, in ACT our aim would be to help the client relate to this rape and all it entails in a more workable way. We can think of the therapist here as having “common sense,” or perhaps as being “perceptive.” The bottom line is that when we consider how to respond to clients we are utilizing fundamental learning principles that describe how we humans learn to do what we do.In the above example, I mentioned various ways you could respond to your client after she has shared something like this in session, and that each represented a differ-ent consequence with the potdiffer-ential for influencing the clidiffer-ent’s behavior in the future. This is an example of the process of operant conditioning— learning by consequences. If what you said or did, or even what you did not say or do, increased the likelihood that the client would share such a secret again, your response positively reinforced that action. For example, if simply being silent resulted in her sharing more of these sorts of things in session, your silence functioned as a reinforcer. If your response decreased the likelihood, it served as a punisher to her sharing.
Moving on, if your client were to tell you that she felt nauseated every time she saw someone who resembled the perpetrator, you would immediately understand why. That is, you would understand that in those instances the other, unknown individual was being associated with the perpetrator in such a way that your client was having the same visceral responses as she did at the time of the rape. Whether or not you would describe it in these terms, you are recognizing the principle of respondent conditioning— learning by association. In fact, it would probably make sense to you if she said that over time she had noticed this association process was growing. Now, even if someone only slightly resembles the perpetrator she feels nauseated, and sometimes just seeing a strange man, period, is enough to make her feel a little queasy. This represents yet another fundamental learning principle, technically termed generalization.
Finally, if the client were to tell you that she quickly removes herself from such situations I’m guessing you would not be surprised. You would understand that she does so in order to escape the unpleasant reactions she is having— a very typical, very human response. As you know, in ACT we call this experiential avoidance, and it is also a learned behavior. Not only would you anticipate that this avoidance might cause problems in her life, you would most likely understand that this sort of avoidant response helps maintain her fear around these types of situations.
I have been pointing out that the learning principles so fundamental to the ACT model are familiar principles that we use in our everyday lives and in the therapy room. This isn’t intended as an intellectual exercise. Just as there are reasons for what we do and don’t do in life, just as there is purpose behind any of the choices we make in the therapy room, there is clear intention behind what we do and don’t do in ACT.
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Advanced ACTThe same fundamental learning principles are at work in all these scenarios. In ACT, having an awareness of these principles is key because that awareness is what drives intention and clinical decision- making. In ACT we work at the level of these princi-ples. More on that in a minute— it’s time to pull in one more essential piece: relational frame theory (RFT), a more recent area of study.
WHAT ABOUT RFT?
My favorite Far Side cartoon is just a single drawing of two cows, clearly a married couple. The male cow is sitting in an armchair with a beer, watching TV, while the wife, in pearls and with wine glass in hand (hoof), stands gazing wistfully out a picture window. “Wendell,” she declares, “I am not content.” The absurdity in this one state-ment reflects much of what is illuminated in RFT. The notion that a cow would have that particular thought is absurd. The notion that a cow would experience this type of discontent (the grass is always greener) is absurd, and particularly funny given the metaphor “contented as a cow.” But why is it absurd? How is it that we understand the situation depicted here is uniquely human? Come to think of it, why is it we humans suffer in these ways to begin with, especially since other species don’t appear to be saddled with this stuff? Basic research into the study of thinking and language acqui-sition began to suggest answers. What’s more, the processes illuminated in this work pointed to something that could be done.
Given its central role in ACT, I suspect there’s not an ACT therapist out there who hasn’t read or heard at least something about RFT. It is a fascinating (I think) and impressive area of study, and expanding rapidly in terms of its relevancy and appli-cation. In the following very selective overview I don’t mean to assume readers are not familiar with RFT. If you are familiar with it, then I hope you will forgive both the review and the license I am giving myself to pull out certain principles and forgo others. If you are not familiar with RFT, however, then perhaps this overview will help forge a connection between this fifth area and the therapy, and spark an interest in learning more about this important area of work. Every piece of RFT matters in terms of helping to develop and refine what we know about language and cognition, which has direct implications for what we do in ACT and for how all of us might approach the business of being human.
I find background helpful, so here’s a brief overview of how RFT came to be: Prior to the development of RFT we did not have a useful theoretical model for the behavior we call thinking. The lack of a model stood in the way of studying and better understanding this important aspect of being human. What began as a behav-ior analytic examination into how verbal rules guide human behavbehav-ior (for example, how it is that the process of therapy— what a therapist says to a client— can actually result in behavior change) eventually expanded to a full-blown model of human lan-guage and cognition. As we learned more about how humans acquire lanlan-guage and how “languaging” consequently functions, we gained clarity regarding some powerful
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abilities particular to humans when it comes to behavior. We began to develop a new understanding of human pathology. Specifically, we began to understand how our rela-tionship with language can result in behaviors that are not very workable. This under-standing, in turn, pointed to the specific abilities needed to respond to life in a more workable way (enter psychological flexibility). Over the course of many years of study, core processes underlying language and cognition were articulated and given empirical support. Processes with significant implications ranging from how we build an identity to how it is that we can suffer from something we have never even actually experi-enced (or that we experiexperi-enced long ago) were revealed. Ultimately a technology— ACT— was developed that provided a means to develop psychological flexibility. More than a way to respond to life “nonpathologically,” this technology offered a way to help humans live in accordance with deeply held values such that “workable” meant living a vital, meaningful life.Relational What?
Let’s touch on some of these abilities humans have when it comes to language and then I’ll move more specifically to the ACT model. The starting point is about the human ability to infer— to relate things to one another. Inferring is deceptively simple, but unique to humans, as it turns out. The most basic explanation of this process that I’ve encountered is simply this: When we learn that A = B, we also infer that B = A. We’ve learned a relation: the same as— or the relation of coordination, as termed in RFT. But it gets more meaningful quickly. That is, we humans have the ability to infer that if A = B, and B = C, then A = C (and C = A). We don’t have to be directly taught that A is the same as C, and that C is the same as A; we are able to “derive that relation,” as said in RFT. Unlike other species (as far as we can tell), we can relate things even if they don’t share physical properties. The expression on my daughter’s face when I tell her that the stuff on her plate is a “vegetable” compared with the expression I would see if I told her it’s “candy” says it all. For her, the learning sequence probably goes something like this:
The icky stuff (A) is called “peas” (B). So icky stuff equals “peas;” A = B. Then she learns through further language acquisition that “peas” (B) are “vegetables” (C), so peas equal vegetables; B = C. She then derives that the icky stuff (A) is a “vegetable” and that vegetables equal icky stuff (A = C and C = A). As it happens, she had also experienced learning along the lines of this: Wonderful-tasting stuff equals “lollipop,” “lolli pop” equals “candy,” “candy” equals wonderful-tasting stuff. Further, the fact that she ignores the vegetable but then asks for candy for dessert suggests she has learned some additional relations, such as that of comparison (candy tastes better than vegeta-bles, candy is preferable to vegetables). And— here’s where it gets really interesting— it’s not just that she knows that peas equal vegetables and that lollipops equal candy; the qualities (icky, wonderful) of each get transformed along with the derived relation. That is, when she scrunches up her face as though eating this never- before- encountered
veg-16
Advanced ACTetable would be an unspeakable horror, it’s clear that her experience of peas has been attached to the word “vegetable” and hence this stuff on her plate. In RFT this process is called transformation of stimulus functions— that is, the way the stimuli (peas), or more specifically the taste of the peas, functions for my daughter (ick), is transformed to anything that falls within this class of things called vegetables. (By the way, the ability to recognize and place something as part of a class represents another type of derived relation, referred to as the inferred relation of hierarchy). In short, with language comes the ability to relate various things in this way, to relationally frame (“frame” used metaphorically, as in how frames contain things). It’s not just that my daughter has learned something about vegetables and candy, but that she has learned something about what “the same as” means, and what “better than” or “worse than” means.
The sequence described above, while inconvenient for a parent, is a relatively benign example of what this ability brings. Languaging (via relational framing) can also bring much suffering. So, for example, one moment my daughter could be dancing with joy, reveling in the experience of moving to music. All it would take to devastate her would be the words “You are the worst dancer in your class.” “Worse than” would have no meaning for her, however, without her having previously learned the relational frame of comparison. Because she has acquired language and the ability to relationally frame, she has learned that “bad” equals something negative, and that “worse” equals more bad. Thanks to a host of other types of relational frames and the transformation of stimulus functions, this notion of being the worst dancer and the shame and hurt associated with it could easily be related to anything framed as being in the same class as dancing, such as performing, athletics, public speaking, or being “out there” in any way. The result could well be that she avoids such opportunities the rest of her life. She will have formed a relational network around “worst dancer in class” that can easily be expanded but not erased. (In other words, history cannot be erased). Enter a particular type of framing called deictic framing (to be defined and discussed at length in chapter 9). Briefly, via deictic framing we learn to build a sense of identity. So for my daugh-ter, her self- concept would now likely include “I am a bad dancer.” By means of the ever- constant relational framing, her self- concept becomes part of a complex relational network and could easily come to include such things as “I am clumsy,” “I am shame-ful,” or even “I am not good enough.” Her very selfhood has now been significantly impacted by that one phrase—which, when you think about it, technically just consists of a combination of sounds.
So relational framing explains a key difference between us and cows. It dem-onstrates, for example, how it is that we can compare our life experience to an ideal (“Wendell, I am not content” or “I am not a good dancer”). It also explains how it is that we respond positively or problematically to things we’ve never encountered, how something that happened years ago can continue to influence how we live our lives now, and how we can perceive ourselves as being fundamentally okay or not okay. Unlike other species, we don’t have to directly experience something in order to have a relationship with it. I learned long ago that venom equals bad, and that a water moccasin equals venom, so water moccasins are definitively bad in my book, although
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hopefully I will go my entire life without encountering one. The relational networks we form around ourselves and our experiences also explain how we come to relate to historical events as though they are in the present. For example, development of relational networks explains how the rape experienced by the client described earlier could lead to an avoidance of men—or even of intimacy, more generally— more than a decade after the actual event.So What?
Now that I’ve gone here, I’ll tell you why I think understanding this stuff at a basic level matters when doing ACT. First, the model starts to make a whole lot of sense, and it is easier to keep the core processes front and center as we move through the therapy. Second, it is easier to keep from doing things that contradict the model if we understand how doing so undermines the psychological flexibility we are hoping to further. Third, we are less tempted to try to “fix” our clients via changing things like self- concept and other internal experiences because we understand language opera-tions (relational frames and networks), and we understand why we must instead look to alter how such experiences function for clients. Fourth, we understand the focus on workability, and the importance of analyzing behavior in terms of its specific context. While I suggested earlier that we naturally employ behavioral learning principles in our lives, being aware of and able to articulate what it is that we are doing expands our options, sharpens our decision- making, and helps us sort out how to respond in challenging clinical situations.
RFT has made a powerful contribution to our understanding of human behavior. RFT demonstrates how it becomes easy to live in a virtual world of relational frames rather than contacting and responding to what is actually happening in the moment. It is the reason ACT targets language, specifically this sort of “verbal dominance.” I have found that some clarity into the actual processes going on here enables me to better work with the language piece of ACT. For example, when we say that, “A thought is just a thought,” we really mean it is just a thought; that is, it is a construction and its meaning has been relationally derived.
Familiarity with RFT is clinically helpful because in clarifying how our relation-ship with language can cause so much difficulty, we see that these difficulties are clearly a fundamental aspect of being human. That is, rather than just going along with the notion that in ACT we strive for a horizontal therapeutic relationship, famil-iarity with the theory helps us see that such a relationship is the only sensible position to take. (While our clients might be caught up with language and thinking in a way that is perhaps more obviously detrimental, we truly are in the same boat in terms of struggling with this stuff.) We can also see that rigidly holding on to the expert role represents our own form of attachment to a conceptualized self, and that this can actu-ally promote behavior that costs our clients (for example, supporting an attachment to a one- down patient or “sick” role, or rule following for the sake of rule following).
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Advanced ACTFinally, for me, it has been profoundly important to understand at a technical level how we go about forming our relationship to the world and especially to ourselves. It is significant to consider that the notions we hold most close are actually derived, that they are essentially learned behavior. So much of what our clients seek is about being fundamentally okay. They want to know whether they are essentially good or not, lovable or not, healthy or not, savable or not. You and I might have our own words for this struggle. Not only can these basic questions never be answered in a way that can be proven (remember “truth” versus functional contextualism?); those very concepts are just more products of languaging. It all reminds me of some TV episode I saw once— I can’t remember where— in which the hero was caught in a spell that made it seem as though he were trapped in leg irons. The only way to escape was to realize that the leg irons were an illusion; until then the chains held fast. I see ACT as a way to help clients see that their leg irons are an illusion, and RFT as demonstrating how the spell was cast.
THE CORE PROCESSES OF ACT
Since this is an advanced text, this next section assumes readers have some familiar-ity with the six core processes of ACT. I’ll cover them briefly just to get oriented, and will take the opportunity to mention some aspects that are sometimes overlooked or misunderstood. This is intended only as an overview, as these points will be discussed more fully in the following chapters.
In the original ACT text, Hayes, Strosahl, and Wilson (1999) organized the pro-cesses into three highly related pairs that comprised three basic response styles: open, centered, and engaged. I find this conceptualization helpful, as it clearly links the pro-cesses targeted in ACT to the learning principles we’ve been reviewing. That is, the science behind ACT illuminated how easily human beings can develop unworkable ways to respond to our experiences. ACT is the clinical response, helping to develop ways of responding that help us move through life very differently. The following is a brief description of these response styles that, together, represent psychological flexibility.
Open Response Style (Defusion and Acceptance)
We hope to develop an open and willing response style as a more flexible alternative to being caught up in verbal content and the effort to escape or control uncomfortable internal experiences. Defusion is the ability to see thoughts as internal phenomena, as representing a behavioral process rather than literal truth. It is the ability to look at thoughts, rather than from thoughts. When this perspective changes, we alter the way in which the thoughts function for clients. This is not about changing the form of the thought itself. The thought is still there, but in seeing it for what it is, the relationship with that thought is altered. The thought functions differently because
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you have altered the context. A common misstep here is to use defusion as a control strategy— as a way to get rid of emotional pain that might accompany the thought, for example. There is a subtle but very important difference in using defusion as a way to hold a thought (and attendant feelings) differently, versus using it to try to change or eliminate that thought and any accompanying emotions. One is about altering func-tion, the other about trying to fix— which in turn supports a very problematic verbal system. It is this sort of necessary distinction that is so aided by understanding the theoretical model in ACT.Acceptance, as viewed in ACT, is the ability to actively embrace thoughts, feel-ings, and physical sensations, even very uncomfortable ones. “Willingness” is also used to denote this process; it’s a term I often use, as it tends to be less loaded for clients and taps into the active nature of this process. A common misperception clients have about acceptance is that it is passive, that it’s about giving up, and so forth. Far from it; acceptance is an intentional and powerful action. Acceptance is also not about a feeling. It is not the feeling of wanting, or whatever, but a stance to take. This is pointed out in virtually every ACT text, but the incessant pull to have discomfort be gone can make both clients and therapists fall back into thinking acceptance is going to somehow lessen discomfort.
Centered Response Style (Present Moment and
Self- as- Context)
What we have learned about how humans get stuck tells us the importance of being centered in the moment and aware of life as an ongoing process. Contact with the present moment refers to the ability to be in the here and now. More than that, in ACT it is defined as consciously contacting the present moment as it is, meaning without buying (fusing with) ongoing evaluations, judgments, and so forth. Doing so allows us to be in direct contact with and observe the actual contingencies of our life (in other words, the ways in which our behavior does and doesn’t work) in a way that creates flexibility rather than more suffering. Of course, “getting present” is actually an oxy-moron. That is, if you are getting somewhere you are not there. Trying to technically get present, as if the present were a destination, is to pursue an ever- moving target. The moment you become aware of a thought, a sensation, a sound, and so on, that moment has already been replaced by the next. So getting present as viewed in ACT isn’t about arriving someplace; rather, it’s about the process of getting out of our heads (defus-ing) and bringing awareness to the stream of experience unfolding in our lives. That process of attention is quite selective, in that it can be directed to the flow of thoughts, to bodily sensations, to any portion of a particular ongoing stream of experiences (for example, “What came up for you just now when I asked about your daughter?” “Notice your breath,” or “I feel like there is something being avoided here— do you sense that as well?”). In fact, the process of bringing attention to the present and determining what to home in on constitutes much of the clinical decision- making in ACT.
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Advanced ACTSelf- as- context refers to the distinction between the self that experiences thoughts, feelings, and sensations, and the experiences themselves. Self- as- context is the most commonly used term for this domain, but it actually refers to just one of three types of self defined in ACT. That is, in ACT we build the ability to promote self- as- process, which is the ongoing noticing of unfolding thoughts, feelings, and sensations, as in “I am thinking X,” or “I am worried about Y.” We help clients detach from the concep-tualized self, which refers to the self- identity that has been constructed from a series of categorizations and evaluations. (Recall the discussion of my daughter as the worst dancer.) Finally, we have what is actually meant by self- as- context. This refers to the experience of the self that has “always been there,” that is distinct from and includes the thoughts, feelings, and sensations of the moment. It is the context in which those phenomena occur, but distinct from those phenomena. It has been referred to as the observing or transcendent self, but a more recent definition emphasizes self- as- context as a behavioral ability, as the process of flexible perspective taking (Hayes, 2011). I have found that self- as- context is the most elusive piece of ACT for therapists and clients, and I will be exploring it more deeply in chapter 9.
Engaged Response Style (Values Clarification
and Committed Action)
Abilities in the previous two sections we have covered help us respond to what life hands us in a workable way. That is, instead of buying whatever our minds tell us, we are able to notice all that mental activity while getting present to our actual lives. Instead of waging a war with our thoughts and feelings, we hold them with interest, curiosity, and compassion. These abilities go a long way toward freeing us up from the more negative aspects of language and cognition. But it is the next dyad, values clari-fication and construction, and committed action, that brings vitality and meaning to our existence.
Values clarification, as used in ACT, refers to identifying how we want to be in the world. Valued living is seen as the ability to engage in a pattern of action that is in line with the values we hold in the different areas of our lives, such as parenting, partner-ship, work, citizenpartner-ship, and so forth. The focus on values is a distinct feature of ACT. It brings the other processes together. That is, “it is only within the context of values that action, acceptance, and defusion come together into a sensible whole” (Hayes et al., 2012, p. 92).
Committed action is about making choices that are in line with identified values. Whereas there’s no actual arriving at a given value, committed action is a series of goals that move the client in a valued direction. Eventually, in ACT, we are hoping to build ever larger patterns of valued (workable) action. I’ve noticed that while com-mitted action is perhaps the most straightforward piece of the therapy— the easiest to
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explain, teach, or write about— it can be the most difficult to manifest behaviorally. Taking committed action is where we want clients to ultimately land. It is where “the rubber meets the road,” and where all the other processes will be put into practice in the service of psychological flexibility.PROBLEMS WITH THE PROCESSES
One problem I’ve noticed in my consulting and supervisory work is that all the refer-ences to “the six core processes” can make it seem as though they are things rather than abilities. Losing sight of this distinction can result in approaching the therapy as a collection of techniques. For example, acceptance and willingness is not a concept to teach to the client but rather a behavioral ability to foster. Another possible implication is that both therapist and client can fall into the idea that there is some destination in ACT, that once you “get” the six processes you arrive at psychological flexibility. This idea—that there is some happiness place out there that they can reach if they just acquire the right knowledge—is part of what gets clients stuck in the first place. In remembering that the core processes are ongoing behaviors, not things, we are reminded that abilities fall along a continuum and that abilities can be developed— all of which is more representative of what actually happens in therapy. Clients don’t tend to suddenly become 100 percent willing or suddenly choose to take value- driven action 100 percent of the time. Rather, these abilities develop over time through applied prac-tice, and will likely continue to ebb and flow as part of the business of living.
A second problem in emphasizing the six essential processes is that we can forget the degree to which these processes are interrelated. While a given process might highlight a particular functional dimension of behavior (such as being present or defus-ing), each process involves the others, and all are ongoing acts that together constitute another ongoing process: the expansion and contraction of psychological flexibility. The fact that the processes are interrelated in this way means that work on any one affects the others, and that there are going to be multiple ways to work with whatever is happening in session.
Just as these abilities combine to promote psychological flexibility, deficits in these areas can lead to real suffering. To summarize thirty years of applied research, the problem is that through languaging and cultural influences, we are essentially set up to respond to life in a way that is closed (rigid and avoidant), noncentered (fused with conceptualized selves, pasts, and futures) and disengaged (caught up in our virtual reality rather than engaging with our actual lives in rewarding ways). Because we are geared to avoid discomfort, we wage a fruitless battle with unwanted thoughts and feelings at the cost of living. Our desire to control and move away from internal dis-comfort is omnipresent and very problematic when it comes at the cost of vital living. Again and again, we fuse with what our minds are telling us rather than simply having what’s there to be had internally and doing what works. Fortunately, we can learn new ways of approaching things, but it isn’t easy. We need both verbal and experiential
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Advanced ACTlearning to help us hold our experiences differently— learning that is consistent and that doesn’t support unworkable, reactive responses.
But Isn’t All This a Strategy?
Well, sure. I have been posed this question from time to time, and it reveals an agenda that is not supported by the model. That is, embedded in the question is the idea that strategies are wrong or bad. Remembering that ACT is based upon a functional contextual account of behavior, there is no rightness or wrongness to having strate-gies, no verbal rule along the lines of “acceptance = good” and “control strategies = bad.” It is about workability. Years of research have taught us that avoidance or sup-pression of unwanted thoughts and feelings can be problematic. We have learned that interventions geared toward altering the form or frequency of these internal experi-ences are not that effective and can actually add to the problem. Focusing on altering how unwanted internal experiences function for clients is offered as a more workable approach. It is certainly a strategy. That’s a problem only if it becomes a problem for the client in some way.
It is important to remember also that unworkable behavior isn’t necessarily about avoidance. That is, it could be that clients are behaving in ways that, while costly, are also rewarding (such as being right, or substance addiction). By furthering the core processes in ACT we help clients defuse from the content of their minds (for example, rigid self- concepts, or rules such as “I have to be right,” or thoughts such as “It won’t matter if I use just this one time”) and get more present to the direct consequences of their behavior (such as distancing others, or not being able to fulfill daily responsibili-ties). The same language processes that can pose difficulties are used to increase the influence of values on clients’ behavior, with the objective of making behavioral choices that are ultimately more workable and that lead to lives with vitality and meaning.
EITHER IN OR OUT
It is sometime in the fall of 2000, and Robyn Walser and I are conducting an ACT group for female veterans participating in a ninety- day residential treatment program for Post- Traumatic Stress Disorder (PTSD). For me, this represents doing ACT, at last, rather than just researching or reading about it. Robyn opens the session, and I listen carefully as she navigates the trickiness of gaining informed consent for a therapy that is hard to explain in advance. I sit back and observe as she skillfully presents the unworkability of the control agenda and the futility of trying to be “more, better, dif-ferent.” I take on the “man- in- the- hole” metaphor and find that I didn’t understand it quite as well as I thought I did. I look invitingly at Robyn and she steps in and makes it all make sense. Soon after, someone in the group asks me a question I didn’t expect; I look at Robyn expectantly. She handles it with ease. Later on, someone suggests this
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therapy is a waste of time. I look at Robyn… .You get the idea. This tendency hung around for a while, too. “You say nothing’s worked but I’ve been sober for fifteen years now!” (Look at Robyn.) “Why is the bus driver the only one who can drive the bus?” (Look at Robyn.) “So I’m supposed to just be okay with what happened?” (Look at Robyn.) And I might as well go ahead and confess that what seemed important in those moments was to conceal my own unknowing— to look as though I was simply being collaborative rather than unsure of what to do. And all this while earnestly hoping to help the group see that attempting to control unwanted thoughts and feel-ings is problematic and unnecessary!There were several missteps here. One was to forget that the behavioral prin-ciples behind ACT applied to me as much as anyone else in the room, which meant I also missed the fact that I was fused with what my mind was telling me (not knowing = incompetence = bad). Another misstep was trying to address content rather than core ACT processes, and a third involved attempting to teach one thing (such as will-ingness) while doing the other (such as avoidance). All of these responses were moving away from the model, although I didn’t realize that at the time. As we will see as we explore the therapy together in this book, these sorts of missteps are easy to make, and can usually be resolved by returning to the core principles of ACT and operating from there. However, it can be a real challenge for therapists to avoid these sorts of missteps and darn near impossible if they haven’t fully bought into the theory in the first place.
I once worked with a supervisee who was up-front about having this sort of ambivalence prior to starting the therapy. This particular supervisee had a lot of train-ing and experience in cognitive behavioral therapy, and explained that even though he understood the theory behind ACT he just wasn’t “sold on the notion that it was always a bad idea to try to improve thinking that was clearly distorted.” Fair enough. Rather than try to persuade him to have different thoughts about ACT, I talked with him about how his position could potentially affect the therapy, particularly in terms of sending mixed messages to the client. We agreed to move forward, with the supervisee holding his ambivalence lightly as he strove to remain consistent with the model while in session.
We found that a certain type of misstep tended to occur. As an example, my supervisee would do a nice job of setting up a cognitive defusion exercise or a self- as- context metaphor, but if you listened closely you would hear that the point being put forth, to help the client have a “different perspective,” was actually about helping the client have a different (improved) thought process altogether, rather than learning to observe and simply experience whatever thoughts showed up. I think most of us can relate to feeling tempted to help our clients with thoughts that seem particularly “irra-tional” and needlessly painful, but if we allow ourselves to dip into content willy- nilly, tweaking this interpretation here and that conclusion there, we risk aligning with the very strategies that got the client stuck in the first place. What we are doing in such moments flies in the face of what ACT has to offer. However, these things can slip in despite our best efforts, and it is difficult to imagine being able to really stay the course if you aren’t fully on board with the theory.
